1. Strategies to Reduce the Incidence of Central Line-Associated Bloodstream Infections Wendy Kaler MPH, CIC Manager of Infection Control Saint Francis Memorial Hospital San Francisco, CA

2. Saint Francis Memorial Hospital

3. Team involvement…..

4. ICU Rounding Active daily interaction of IC as part of the ICU PI team Active daily interaction of IC as part of the ICU PI team –Focus on NEED for indwelling central line –D/C of femoral lines –Catch early indications of infection

5. ICU Rounding Photo here

6. Feedback to staff Cheerleading # Days since last infection as calculated by Infection Control Updated weekly

7. Celebrate milestones

8. Process Improvements…….

9. Insertion of Central Lines Bundles – –IHI – –Provonost (NEJM Dec 28, 2006) – –Joint Commission NPSG#7 – –CA SB 739 Early use of PICC in neonates

11.  Link to: NNIS Online at CDCNNIS Online at CDC Fact: Catheters and other invasive devices are the # 1 exogenous cause of hospital-onset infections. Prevent Infection Step 2: Get the catheters out 12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults

12. Central Line Needs Assessment During daily rounding During daily rounding Sticker in Physician Progress Notes Sticker in Physician Progress Notes EMR mandatory field EMR mandatory field

14. Maintenance Bundle for Central Lines Most CL-BSI occur > 5 days after insertion Most CL-BSI occur > 5 days after insertion Stabilized lines Stabilized lines Timely dressing changes per policy- dressings dated Timely dressing changes per policy- dressings dated Skin antisepsis at insertion site Skin antisepsis at insertion site Dressings dry and intact Dressings dry and intact Cleaning of port prior to accessing Cleaning of port prior to accessing

15. Successful Disinfection of Needleless Mechanical Valve Access Ports: A Matter of Time and Friction Kaler, W., Chinn, R. JAVA 12(3) Fall 2007 Rady Children’s Hospital Sharp Memorial Hospital

18. Conclusion We provide evidence that when access ports are subjected to the industry recommended disinfection time of 15 seconds with friction, alcohol alone or chlorhexidine/alcohol were equally effective in sterilizing MV ports inoculated with a 10 5 CFUs suspension of microorganisms, regardless of whether the MVs were constructed using positive, negative, or neutral displacement technologies. We provide evidence that when access ports are subjected to the industry recommended disinfection time of 15 seconds with friction, alcohol alone or chlorhexidine/alcohol were equally effective in sterilizing MV ports inoculated with a 10 5 CFUs suspension of microorganisms, regardless of whether the MVs were constructed using positive, negative, or neutral displacement technologies.

19. IV Access Port Protection Caps Alcohol-impregnated caps-remain on the ports between use Iveramed- Curos Excelsior Medical

20. Port Protection Caps Advantages Decreases nursing time required to comply with “port disinfection policy” (NPSG#7) Allows for monitoring of compliance with port disinfection policy (NPSG #7) Potential reduction of contaminated line-drawn blood cultures – –Appropriate antibiotic use – –Accurate CLABSI rates for PUBLIC REPORTING/CMS Reporting

21. Nursing Attitude & Focus on Infection Control Practices Barriers to following good infection control practices include: – –Not enough time – –Not enough resources – –Not enough information – –It is really not that important – –Not able to focus on task at hand due to many distractions

22. Nursing Attitude & Focus on Infection Control Practices Possible solutions: - Get staff level nurses involved in designing solutions - Make it personal - Provide evidence of effectiveness of methods - Provide local data/risk - Feedback of poor outcomes

23. Culture of a patient’s port surface

24. Staff EDUCATION Re-usable Post-It® poster on each nursing unit… messages changed as needed

25. Making it Personal… Our IV TEAM Lead posing as a patient

26. Infection Control It’s an ATTITUDE … Provide care as if it were YOU in that bed……

27. How do you know it’s a CLA-BSI? Are you involved in the RCAs?

28. Specimen Collection Garbage in = Garbage out Public Reporting  Antibiotic Resistance

29. LCBI Surveillance Definitions CRITERION 3 Patient <1 yr has at least one of the following signs or symptoms: fever, hypothermia, apnea, bradycardia AND Signs and symptoms and lab data not related to infection at another site AND A common skin contaminant cultured from 2 or more blood cultures drawn on separate occasions (within 2 days).

30. For QUANTITATIVE blood cultures Ascher et al Diag Microbiol Infect Dis 1992 Aug 15(6) 499-503 ≤10 CFU not significant (Bradley, J. et al)

31. Non-ambiguous Blood Culture Results Peripheral vs line draw Line-draw technique – –DISCARD 1-3 ml Labeling of bottles Full info in lab report NO Catheter tip cultures

32. LCBI Surveillance Definitions CRITERION 1 Patient has a recognized pathogen cultured from one or more blood cultures AND Organism cultured from blood is NOT related to an infection at another site

33. LCBI Surveillance Definitions CRITERION 3 Patient <1 yr has at least one of the following signs or symptoms: fever, hypothermia, apnea, bradycardia AND Signs and symptoms and lab data not related to infection at another site AND A common skin contaminant cultured from 2 or more blood cultures drawn on separate occasions (within 2 days).

37. ZERO is the goal….. Process and teamwork (good relationships) get you there…..